This chapter explores the struggles of the neighborhood of Southton, one of a cluster of four neighborhoods in a single Pittsburgh City Council district highlighted as the center of the cityâs opioid overdoses and deaths. Drawing on research connecting opioid use disorder to deeper social and relational dynamics within American life, this chapter seeks to situate opioid use disorder within a broader context of community decline. Certainly, this discussion does not discount the hard work of public health professionals, treatment centers, and others in helping people recovering from this devastating disease. But if the opioid epidemic is a social illness as much as it is a pharmaceutical one, then its treatment requires attention to social factors, as well. What is more, locating the roots of opioid use disorder within the fraying social fabric of American life reminds us that the opioid epidemic is connected to a much deeper affliction demanding a much more radical response.
The Struggles of Southton
Despite the challenges they have faced, Southton and its surrounding neighborhoods have been making steady progress in reducing the opioid epidemicâs lethality. In Allegheny County, where Pittsburgh is located, policy makers and treatment providers focused their resources at the height of the crisis on medication-assisted treatment (Allegheny County Department of Human Services et al. 2017), as well as on harm reduction interventions such as targeted naloxone distribution (Hulsey et al. 2019; Kolla and Strike 2019) and syringe services programs (Boden 2018) that can make using opioids safer. These strategies align with guidance at the national level from both the Centers for Disease Control and Prevention (Carroll, Green, and Noonan 2018) and the Department of Health and Human Services (2018), which prescribe collaborative approaches blending naloxone distribution, needle exchanges, and medication-assisted treatment in jails, emergency rooms, and community settings, as well as increased outreach to health care providers to reduce the prescription of opioids in pain management, Good Samaritan laws releasing bystanders from any legal liability arising from helping persons who have overdosed, and the inclusion of fentanyl in routine drug screens. These efforts bore fruit: As the number of fatal overdoses nationally increased from 2017 to 2019 (National Institute on Drug Abuse 2020), statistics from the Pennsylvania Department of Health (2020) show that the number of opioid overdose deaths in the Commonwealth between 2017 and 2019 decreased from 5,398 to an estimated 4,125, a 23.6 percent decline. The mortality rate in Allegheny County decreased slightly faster, dropping 27 percent over the same period, from 981 deaths in 2017 to 716 deaths in 2019 (Overdose Free PA n.d.), the year during which the current study took place.
Yet, these intervention strategies, important as they are, only manage what Katherine McLean (2016), following the work of Tim Rhodes (2009), calls the micro-level risk environments that
concern the physical spaces of drug use, local norms around drug consumption and strategies for its policing, lack of income and access to health care, and the effective (un)availability of harm reduction programs, educational materials or tools (including clean syringes and naloxone).
(22â23)
Writing about the experiences of people struggling with opioid use disorder in McKeesport, a city in Allegheny County only about a 30-minute drive away from Southton, McLean (2016, 24) emphasizes the importance of the macro-level risk environmentââthe stagnant economy, institutional culture, and overall atmosphereâ that interacts with, complicates, and frustrates micro-level interventions. McLeanâs (2016, 24) subjects âwere overwhelmingly pessimistic about the feasibility and success of any overdose interventions that did not simultaneously address the stifling poverty of the region or the alienation and despair of McKeesportâs dwindling populace.â Although naloxone clearly saves lives, McLean (2016, 24) concludes that addressing opioid use disorder requires paying attention to what is lacking in the macro-level environment, which includes ânot only jobs but also residents, effective government, social events and activitiesâ that give people constructive alternatives to drugs. McLeanâs study suggests that understanding the macro-level risk environment can not only shed light on the deeper, structural factors that lead people to become addicted to drugs but also help plan interventions aimed at the root causes of opioid use disorder, which is increasingly understood to reflect social, political, and economic causes as much as individual differences and choices (Becker 2018; Saloner et al. 2018).
Understanding this broader context may explain why the epidemic has been so pronounced in Southton. In comparison to Pittsburgh as a whole, Southton is primarily white: According to the 2018 American Community Survey, 89.7 percent of its 13,884 residents are white and only 4.6 percent are Black, whereas 66.9 percent of Pittsburghâs 303,587 population is white and 23.2 percent Black. Southton is also wealthier: The median income is $54,746, in contrast to the city of Pittsburghâs median income of $47,417, and 71.3 percent of households own their own homes, while only 46.9 percent of the homes in Pittsburgh are owner-occupied. Still, the neighborhood, much like many parts of Pittsburgh itself, has struggled since the demise of the steel industry in southwestern Pennsylvania during the mid-1980s, a collapse journalist John Hoerr (1988) frames as a massive trauma event touching every aspect of the regionâs life and people. The loss of stable employment forever shattered a social contract that until then had presupposed perpetual prosperity. After decades of fighting bitter and at times bloody struggles for dominance, Hoerr writes, labor and management had forged a tacit and brutally simple compromise: Management would pay high wages in return for unions refusing to strike. Mill towns resisted anything that would alter the tense detente, giving rise to what Hoerr sees as a mentality defined by low expectations and an even narrower capacity to adapt to change. When foreign competition and economic pressures made the social contract null and void, the effects were profound. Though the workers attempted to remain resilient in the face of change, their neighborhoods quickly died, young people left as soon as they could, suicide rates increased, fragmented local municipalities went bankrupt, and the public infrastructure fell into decay.
Some parts of the city have rebounded since then, driven by the health care, higher education, financial services, and technology sectors. But neighborhoods have not benefited equally. In some areas, the unevenness in development surely comes down to structural racism, but in places such as Southton, separated from the city center and the university communities by the Monongahela River, the cause may be more geographic. But regardless of the reason, Southton, like the other neighborhoods in its city council district, has been left behind. Southton Boulevard, which cuts through the community and was once a thriving business district, is a shadow of its former self, defined by cell phone stores, pizza parlors, and litter. And while not technically a food desertâSouthton has a few convenience stores and smaller markets where residents can buy some necessities, and public transit is decentâthe neighborhood of nearly 14,000 people has only one real supermarket located on its edge. Participants in the study reported having to travel outside of the community for much of their shopping, leading to a sense of dependency, frustration, and decline.
Although the decline of Southton Boulevard and the lack of quality shopping may seem to be merely cosmetic, Eric Klinenberg (2018) contends that these spaces have tremendous implications for the quality of the social connections that people make. When people work together, shop together, encounter each other, and feel safe together, they have the opportunity to sustain relationships that provide vital resources to help them thrive in normal times and survive moments of crisis. âLocal, face-to-face interactionsâat the school, the playground, and the corner dinerâare the building blocks of all public life,â Klinenberg (2018, 5) writes, and without these interactions, social trust declines, participation in institutional life suffers, and people experience higher levels of alienation that harm their physical and emotional health. The results of this social decline increasingly emerge in the opioid epidemic in what Princeton University economists Anne Case and Angus Deaton (2020) have provocatively called âdeaths of despair.â
Social Despair, Social Connection, and Social Capital
To be sure, Case and Deatonâs (2020) work needs to be treated with care. Even as their catchphrase has captured the imaginations of pundits and policy makers alike, numerous researchers have raised important concerns. Alleviating âdespairâ is an ambiguous basis for public policy, they have argued, and the focus on the experiences of non-Hispanic whites without college degrees ignores the despair endemic to Black, Latinx, and Native American communities for centuries (Diez Roux 2017; Komro 2018; Muennig et al. 2018). Yet, Case and Deaton are not so much writing marginalized communities out of the story in favor of working-class whites as they are making a sobering commentary on the widespread dysfunction, vulnerability, and inequality now tearing at the fabric of every aspect of American life. Today, large segments of Americans, regardless of race, now find themselves leading isolated, unvalued, and precarious lives in a country that has left them behind. They argue that as these disparities widen and become more apparent to those on the bottom, and as those on the top move more aggressively to protect themselves from a similar fate, the despair and anger will only deepen, with devastating social consequences for decades to come.
Richard Sennett (1998) writes that the profound despair Case and Deaton (2020) see as being experienced by ever-larger and ever-more diverse percentages of American society suggests a powerful story that helps disenfranchised people make sense of their experience. But the story of despair, with its combination of self-blame and frustration at oneâs own circumstances and anger at the elites believed to be responsible for creating those conditions, is profoundly corrosive for community life. Lilly Shanahan et al. (2019) observe that despair, as a construct, speaks to a complex web of cognitive factors (e.g., thoughts of worthlessness or hopelessness), emotional factors...
